Chicago's HIV Epidemic, Continuum of Care and Targets to Reach

Chicago’s HIV Epidemic, Continuum
of Care and Targets to Reach
Chicago Department of Public Health

NHAS Goals

CAHISC – Data Day

Nanette Benbow
August 3, 2012
Rahm Emanuel Bechara Choucair, MD
Mayor Commissioner

Overview
• Prevention and Care Framework and Priorities

• Epidemiology of HIV in the EMA
– Description of Those at Risk of HIV
– Prevalence of HIV in high risk populations
• Characteristics of People Aware of their status
• Characteristics of those newly diagnosed
• Characteristics of those unaware of their status
• HIV continuum of care in the Chicago EMA – linkage
to care, engaged in care and viral suppression
• Reaching the NHAS goals

Mayor Commissioner

CDPH – STI/HIV Surveillance, Epidemiology and Research Section – 08/2012

National HIV/AIDS Strategy
Reduce new HIV infections
– Lower the annual number of new infections by 25%
– Reduce HIV transmission by 30%
– Increase the percentage of people living with HIV who know
their serostatus from 79% to 90%

Increase access to care and improve health outcomes for people
living with HIV
– Increase the proportion of newly diagnosed patients linked to
clinical care from 65% to 85%
– Increase the proportion of Ryan White HIV/AIDS Program clients
who are in continuous care from 73% to 80%
– Increase the number of Ryan White clients with permanent housing from 82% to 86%

Reduce HIV-related health disparities
– Improve access to prevention and care for all Americans
– Increase the proportion of HIV-diagnosed gay and bisexual men, Blacks and Latinos with
undetectable viral load by 20%

CDC – High Impact Prevention: Maximizing
Limited Resources for HIV Prevention
• Proven HIV Prevention Interventions
– HIV testing and linkage to care
– Antiretroviral therapy
– Access to condoms and sterile syringes
– Prevention programs for people living with HIV and their partners
– Prevention programs for people at high risk of HIV infection
– Substance abuse treatment
– Screening and treatment for other sexually transmitted infections
– Pre-exposure prophylaxis PrEP for select populations

Test and Treat – Treatment as
Prevention


HRSA Continuum of Engagement

Not in Care Fully engaged

Unaware Aware of May be Entered HIV In and out Fully
of HIV HIV receiving medical of HIV engaged
status status other medical care but care or in HIV
care but not dropped out infrequent medical
HIV care user care

Cheever. Clin Infect Dis 2007;44:1500-1502

The Continuum of HIV Care – Gardner
Cascade

Stacy M. Cohen, MPH, Michelle M. Van Handel, MPH, Bernard M. Branson, MD, Janet M. Blair, PhD, H. Irene Hall, PhD, Xiaohong Hu, MS, Linda J. Koenig, PhD, Jacek Skarbinski, MD,
Angie Tracey, Jonathan Mermin, MD, Linda A. Valleroy, PhD. Vital Signs: HIV prevention through care and treatment—United States. MMWR 2011;60(47):1618–1623.

Epidemiology of HIV in the EMA

Mayor Commissioner

HIV Prevalence and Awareness of HIV
Infection, National HIV Behavioral
Surveillance (NHBS), Chicago
MSM IDU HET MSM
2008 2009 2010 2011
n=523 n=527 n=514 n=453

HIV prevalence 17.4% 5.5% 1.2% 20.9%

Unaware of 50% 48% 50% 24%
infection


Unrecognized HIV Infection by Race,
NHBS Chicago 2011
Total Unaware HIV + 2009
HIV +
# # (%) (%)
Black 46 16 35 66
White 35 3 9 23
Hispanic 14 4 27 50

Total 95 23 24 50


HIV Risk Behaviors, Past 12 months,
NHBS Chicago
MSM IDU HET
Unprotected vaginal sex -- 71% 89%
Unprotected anal sex 52% 24% 32%
Shared syringes -- 24% --
Shared injection equipment -- 51% --
Tested for HIV infection in 12
64% 49% 33%
mo prior to interview
Participated in HIV
23% 18% 9%
behavioral intervention
Access to Free Condoms 82% 75% 44%


People Living and Diagnosed with HIV
and AIDS, Chicago, 1992-2010


Changes in the HIV Epidemic,

Chicago EMA, 2000-2010, as of
6/12


HIV Infection Transmission Category Percent
Distribution in Large Cities in the US, 2007


People Living with HIV* in 2010 by Select
Characteristic, Chicago EMA, as of 6/12

*N = 27,533

2010 HIV Infection Diagnoses* in the EMA
by Select Characteristic, as of 6/12

*N = 1,402

Subpopulations with the Largest Numbers of
New HIV Infection Diagnoses, Chicago EMA,
2005 & 2010, as of 6/12

Trends in Male HIV Infection Diagnoses
by Race/Ethnicity, Chicago EMA,
2000-2010, as of 6/12


Trends in HIV Infection Diagnoses by Mode
of Transmission, Chicago EMA,
2000-2010, as of 6/12


Trends in Female HIV Infection Diagnoses by
Race/Ethnicity, Chicago EMA ,
2000-2010, as of 6/12


Trends in HIV Infection Diagnoses in
MSM by Race/Ethnicity, Chicago EMA,
2000-2010, as of 6/12


Trends in HIV Infection Diagnoses by Age,
Chicago EMA, 2000-2010, as of 6/12


Trends in HIV Infection Diagnoses in
MSM by Age, Chicago EMA,
2000-2010, as of 6/12


Trends in HIV Infection Diagnoses Among
Black MSM by Age, Chicago EMA,
2000-2010, as of 6/12


Current HIV Continuum of Care,
Chicago EMA, 2010 as of 6/2012

Test Link & Treat Prevent



Testing

Mayor Commissioner

HIV-related Services among MSM Aware of
HIV+ MSM
who know their status (n=72)
their Infection, Chicago 2011, NHBS
Black (n =30) White (n =32) Hispanic (n =10)
(%) (%) (%)

Diagnosed in past 2 years 60 34 50

At diagnosis – partner 57 38 33
services offered

Tested for STI, past year 65 72 90

67 84 70
Vaccinated for Hep A/B


Ever Tested for HIV Before 1st Positive Result,
Chicago, MMP 2011 Local Questions


Main Reason for Never Being Tested for HIV
Before the 1st Positive Result,
MMP 2011 Local Questions

*missing responses excluded

A) Late Testers

People who are diagnosed with HIV as well
as AIDS in the same calendar year.

Percent Distribution by Select Characteristics in
2010, Chicago EMA, as of 6/12
Late Testers

B) People Unaware of Status Using
CDC 2009 Estimate of 18%

Estimates of People Unaware of Their
Status, Chicago EMA, 2010
Percent
2009 National # Unaware Distribution of
Estimates of % Using National Estimated
2010 Prevalence Unaware Estimates Unaware
Male 21,561 19% 5,058 82%
Female 5,972 15% 1,079 18%

Black 13,656 19% 3,287 57%
White 7,701 15% 1,338 23%
Hispanic 4,782 20% 1,173 20%

MSM 15,651 21% 4,135 68%
IDU-male 2,695 10% 299 5%
IDU-female 1,763 9% 170 3%
MSM/IDU 1,582 9% 158 3%
HRHC-male 1,386 24% 447 7%
HRHC-female 3,976 18% 849 14%

Total 27,533 18% 6,085 100%


% Distribution of People Unaware and Unaware of Their
Status by Select Characteristics, Chicago EMA, 6/12
Unaware


HIV Continuum of Care in the
Chicago EMA

Mayor Commissioner


Linkage to Care

Mayor Commissioner

Linkage - Percentage of HIV Diagnoses
Linked to Care, Chicago EMA, 2010


Percentage Linked to Care within 12
months of Diagnosis by Select
Characteristics, Chicago EMA, 2009


Main Reason for Selecting Care Location

*missing response excluded


Access/Retention in Care

Mayor Commissioner

HIV Care among MSM Aware of their
HIV+ MSM
who know their status (n=72)
Infection, Chicago 2011, NHBS
Black (n =30 ) White (n = 32) Hispanic (n =10 )
(%) (%) (%)

Seen doctor for HIV care 100 97 100

Currently on ART 80 91 80

2008 43 83 79

Know CD4 count 100 94 100

Know Viral Load 97 91 80

Retained in Care - Percentage of People in
Care, Chicago EMA, 2009, as of 3/12


Percentage of PLWHA in 2010 with Unmet
Need* by Select Characteristics, Chicago EMA,
as of 8/11

*No laboratory reports of a CD4, VL or indication of being on ART


First Entered Into Medical Care System for HIV,
# %
Medical evaluation at the time of diagnosis 34 17
Appointment scheduled for medical
evaluation at the time of diagnosis 44 22

Referral for doctor given 47 23
Self motivated 66 32
Family or friend motivated 6 3
Other 6 3
Total 204*

*missing response excluded

Providers Office Reminders

(for scheduled appointments)

*missing responses excluded

Care Interrupted,
•19% (38/205) had their care interrupted for a period of more
than 6 months consecutively at least one time since being
diagnosed
•56% only once
•44% two or more times
•Reasons provided for most recent time:
•Drinking or using drugs
•Missed appointment(s)
•Didn’t have enough money or health insurance
•Had other responsibilities
•Felt good
•Dissatisfied with care from provider
•60% said there were no attempts made by provider at the
most recent occurrence to restart their care


Prescription on ART and
Viral Suppression

Mayor Commissioner

PLWHA in Care, Chicago MMP, 2009
Among those prescribed
ART, most recent HIV
viral load test indicating
Prescription of ART† <=200 copies/mL†
weighted % (95% CI) weighted % (95% CI)
Age**
18-29 87 (71-100) 86 (67-100)
30-49 81 (74-88) 82 (73-90)
50+ 88 (81-94) 87 (81-92)
Sex
Male 89 (84-94) 85 (79-91)
Female 69* (58-80) 79 (66-93)
Race/Ethnicity
Black or African American 81 (75-88) 80 (74-87)
Hispanic or Latino 81 (68-95) 80 (65-95)
White 92 (84-100) 100 (100-100)
Other 100 (100-100) 43 (0-86)
Sexual risk behavior^§
Men who have sex with men (MSM) 90 (85-96) 90 (84-95)
Black MSM 89 (81-98) 86 (78-95)
Hispanic MSM 89 (73-100) 83 (66-99)
White MSM 92 (83-100) 100 (100-100)
Young MSM (18-29) 92 (77-100) 87 (63-100)
Men who have sex with women only (MSW) 84 (73-94) 71 (57-84)
Women who have sex with men (WSM) 71* (59-82) 79 (66-93)

Total 84 (80-89) 84 (78-90)
*Significant p<.05 CDPH – STI/HIV Surveillance, Epidemiology and Research Section – 08/2012

Indicators of Care Among Ryan White
Ambulatory Care Part A Clients*, Chicago
EMA, July 2010-June 2011
NHAS Target:
Increase % of RW clients
engaged in care to 80%

*N=11,220; Engaged in care= 2 CD4/VL at least 3 months apart


Current State and Future

Outcomes

Mayor Commissioner

5-Year Chicago EMA Targets if
NHAS Goals are Reached


For every 100 people estimated to be
living with HIV in the Chicago EMA…..


Conclusions
• There has been considerable progress in getting
people tested earlier, aware of their status and linked
to care across all demographic and risk groups
• The characteristics of those aware of the their status is
not that different from those unaware, thus, similar
targeting efforts can be used across the continuum –
focus on reducing disparities
• The percent of people on ART varies by demographic
and risk groups and has increased among MSM
participating in NHBS
• Success in reaching NHAS goals in the EMA will require
coordination and collaboration between public and
private institutions/agencies providing prevention and
care services


Chicago's HIV Epidemic, Continuum of Care and Targets to Reach

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